Author: Maria Yang, MD

Categories
Lessons Reflection

Your Six-Foot Radius.

I don’t think I was that mouthy during my medical training.

Some East Asian women are shy, deferential, and taciturn. It’s no wonder some people were surprised when critical comments came out of the mouth that is attached to my face.

Advocacy comes in different flavors. My initial attempts were salty.

While I didn’t occupy the lowest rung on the neurology service (that honor went to the medical students), I was but an intern. Furthermore, I wasn’t even an neurology intern. I was training to become a psychiatrist.

The attending neurologist, who looked like those doctors exalted in enormous oil paintings that adorn the hallways of hospitals, had too many letters after his name. He also riffed on too many subjects unrelated to neurology during our morning rounds.

Rounds in academic medical centers serve two main purposes: To organize care for patients, and to educate trainees. The team, under the guidance of the attending physician, executes the plan of care for each patient following rounds.

One autumn morning we stood in a circle outside of a patient’s room. Rounds were just starting. Patients—and a whole lotta work—awaited us.

“It’s the season for soup,” the attending neurologist opened, smiling. “Chief Resident, what is your favorite kind of soup?”

I couldn’t restrain myself.

”Can we not talk about soup? There are patients waiting and work we need to do,” I snapped. My fellow intern, a future emergency physician and more accepting of reality than me, didn’t stifle his laughter in time.

Both the chief resident and frowning attending physician shot me a look. “I know you’re focused on getting work done, Dr. Yang,” the chief resident chided, “but there is time to talk about other things.”

My cheeks burned. But no one spoke more of soup. We started talking about the patient waiting in the room. 



Three years later, I myself became a chief resident. Junior residents shared with me that one of the attending psychiatrists, another decorated physician considered a national expert in his field, wasn’t meeting with them for supervision. This was one of his responsibilities. Esteemed professors were supposed to spend time with us trainees so we could learn from them. He wasn’t doing his job.

Chief residents have some responsibility to advocate for junior residents. Annoyed, I asked to meet with him. This flavor of advocacy was spicy.

He didn’t ask for an agenda ahead of time and I didn’t think to provide one. After sharing with him what residents told me, I said, “It is your responsibility to meet with residents for supervision. Why isn’t this happening?”



Well, you can imagine how that went. He became shouty, waved his arms, and wondered how I, a mere resident, had the audacity to talk to him that way.

My cheeks burned again. However, he didn’t deny the allegation.

My program director was dismayed—maybe embarrassed on my behalf?—when I told her what happened. “You didn’t need to tell him yourself!” she exclaimed. “You could have told me and I could have spoken with him.”

The junior residents told me later that he had reached out to schedule regular supervision with them all. 



With additional experience (read: missteps and errors), my advocacy is now more mellow. I’ve learned to ask more questions, orient people ahead of time, and be more mindful of power and status. When all else fails, be direct.

The word “advocacy” often conjures political images: chanting slogans at rallies or calling elected officials.

But those aren’t the only ways to advocate for ideas you value. Effective advocacy can happen within our six-foot radius. It’s asking questions or making statements. Sometimes, it only takes a short conversation to start shifting long-held assumptions:

“Quite frankly, I wish the president would give us a purge [of homeless people]. Because we do need to purge these people.”

“I wonder what the parents and friends of homeless people would think of that plan. What hopes and dreams do you think they had as kids? Surely they didn’t aspire to be homeless.”

“Every time I find one of these lunatics, I take away their visas.”

“When you say ‘lunatic’, what does that mean? What is the process for applying for a visa, anyway? It’s following the law, right?”

“The probability of a trans person being violent appears to be vastly higher than non-trans.”

“I don’t think that’s true, but let’s look at the data together. Where can we look to learn accurate information?

Advocacy can look like curiosity. At its sweetest, advocacy illuminates the humanity of others. Such reminders can take just a few seconds.

To be clear, this doesn’t mean talking to anyone and everyone who enters your six-foot radius. A small minority of people are not curious and not interested in dialogue. They seek targets for their frustration and anger. If you’ve tried to make a connection in good faith, but the effort is not reciprocated, stop. Sometimes, quitting is the best option.

In times—these times—when problems feel too big for us to understand or solve, when we feel like nothing we do makes a difference, speaking up still matters. Your statements (or silence!) affects other people.

Advocacy doesn’t have to involve bullhorns or giant signs. Do not obey in advance. Have faith in what you can accomplish within your six-foot radius.

Categories
Observations

A Pope’s Death.

If he views attention as a zero-sum game, then, today, he lost. To a dead man, no less—a man who did not even rule over a state. He was just a pope.

But he’s a president. What power he wields! World leaders must navigate around him. Stock markets tumble when words fall from his lips. His thumbs tap out a tweet, and the media pores over his words.

The Pope merely died — why did he get all the attention today?

Grief from the Pope’s death has led to his eternal life. When the newspapers aren’t writing about the president, why does it seem that he is no longer relevant? And if he’s not, has his power disappeared, too?

To confirm he exists, his presence must be felt. So he pulls levers. Some produce adoration; others produce anger. These emotional reactions are proof: He still exists. He still matters.

Here’s the betrayal: The absence of the Pope has cemented his presence forever. A dead man has stolen all the attention that the president believes is rightly his. What will he do now to get it back?

Today may remain quiet. But let’s see what happens tomorrow.

Categories
Funding Homelessness Policy Public health psychiatry

Geriatric Homelessness and Medicaid.

I submitted the following as an op-ed essay, though neither local publication accepted it. (I understand: Many people have many opinions about all the actions and inactions happening these days.) The tie-in with Medicaid is important, though I more want people to know this: There are people who are old enough to be your parents and grandparents who don’t have a place indoors to call home.

A van has been in the same parking spot in South King County for over six months. Inside are unopened water bottles, packages of adult diapers, trash bags—and a man. He is over 70 years old. Though he isn’t sure what year it is or the name of the current president, he knows that he wants to live in an apartment. He just doesn’t know how to make that happen. 

In another city park in South King County, a woman sits alone next to a trash can. Her black wire pushcart is stuffed with plastic bags. The stink of urine that surrounds her keeps people away. The trees are bare, a cold breeze is blowing, and she thinks it is a Saturday in June. She is also in her 70s. She slept outside last night, as she has for several years. The only topic she can speak of with confidence is her pet cat.

These are not isolated tragedies. They are alarms. If Congress follows through on its proposed Medicaid cuts, more vulnerable older adults—including those with dementia—will be forced onto the streets. This is unacceptable.

Older adults with memory problems who live outside seem like exceptions. In fact, they are part of a growing population. The US population is older than it has ever been. The number of Americans over the age of 65 is projected to increase by millions in the coming decades. Increasing age is the greatest risk factor for the development of dementia.

The California Statewide Study of People Experiencing Homelessness revealed that nearly half of single homeless adults were over 50 years old. Of them, over 40% became homeless for the first time at age 50 or older. Many of these older adults are eligible for Medicaid because they are poor. If they had more money or support, they would not be living outside. 

Dementia, like other chronic illnesses, drains savings. The costs of care add up fast. In Washington State, in-home caregiving services average over $31 an hour. Facility-based care, such as an assisted living facility, is also expensive–nearly $7000 per month. Skilled nursing facility costs are even higher. Many older adults run out of money.

This is where Medicaid funding for long-term care comes in. The federal government pays for over half of these Medicaid long-term care services and supports. For many, Medicaid is the only reason they have a place to call home.

Cuts to Medicaid would slash payments to long-term care providers. Staff would be laid off. Facilities would close. What about those with no family support or money? They will have nowhere to go. We will see more older adults, including those with dementia, living outside. No one wants this. Right now, Medicaid is the last safety net catching older adults before they fall into homelessness.

It is possible that Congress will protect Medicaid funds directed towards long-term care. President Trump has said that his federal administration will “love and cherish” Social Security, Medicare, and Medicaid. However, proposals from Congress show a clear desire to divert funds from these programs that thousands of older King County residents rely on. 

The man in the van ultimately agreed to go to a local hospital for brewing medical problems. From there, he was discharged to a skilled nursing facility. He was thankful: This is the first time he’s lived indoors in years. Medicaid made this possible. 

The woman remains outside. Without Medicaid, thousands more older adults will join her. That is the future Congress is choosing if it cuts Medicaid. 

Categories
COVID-19 Policy

Standing Up.

Five years ago I was working as the medical director at the largest homelessness services agency in Seattle.

My dad, who skimmed headlines from major newspapers in the US and China every morning, had been tracking news about a respiratory illness spreading in China. “It sounds bad,” he said in January.

On February 29th, 2020, the first death from Covid happened in the US. The death happened in a suburb of Seattle called Kirkland. (If you are a Costco member, those Kirkland jeans and Kirkland cookies and Kirkland laundry detergents are named after the city where the original Costco headquarters were located.) Without consulting the executive director, I sent out an e-mail to the entire agency that same day. I can’t remember what I wrote, though my intention was to offer information, presence, and transparency.

I couldn’t offer true reassurance. I knew nothing. I was worried.

At that time there were close to 50 medical professionals at the agency. During a meeting that happened shortly thereafter to consider next steps, one of the psychiatrists, his voice quavering, asked, “We’re going to shut down the [program he worked in], right?”

“No,” I said, perplexed. “People need that program — and they might need it even more because of what might come next.”

That psychiatrist then abandoned his job. No notice, no explanation. He just left.

Everyone else on the medical team stayed. Though I have expressed my gratitude to them many times, they will never fully understand the depth of my appreciation. There is no way the agency could have kept people — most currently or formerly homeless — well without their help. They applied their knowledge and skills in unknown territory, sought out patients wherever they were, and worked within and across disciplines. There were hundreds of staff at the agency and well over 2500 patients. By the summer of 2022, only five patients had died from Covid. (More died with Covid, but SARS-Cov2 was not the primary cause of death.)

During the Stand Up for Science rally in Seattle yesterday, the president of the Washington State Nurses Association spoke. He talked about the service of nurses during the pandemic, how they all continued to show up and work despite the threat of disease and death.

His point was two-fold: Nurses need science to do their jobs. Nurses also do the right thing: They don’t back down in the face of threats. They keep showing up, even when the situation is scary and hard.

This is true for the vast majority of people who work in health care.

Do I feel great annoyance with the current federal administration? Yes. Do I think people will suffer and die unnecessary deaths because of their policies? Yes. Does that enrage me? Yes.

Serving as the medical director at that homelessness services agency during the pandemic was the hardest thing I’ve ever done in my professional career. The fruit of that experience, though, is an unexpected equanimity.

It’s not that I don’t feel worry or sadness. I do. The actions of the federal administration just seem like a series of surmountable problems. Their triumph is not inevitable. All of us who were essential workers during the pandemic showed up, did our jobs, and supported the people in our communities. If we were able to do that when the threat was unknown, global, and indiscriminate, why would we be cowed by a shrinking faction of spiteful people?

Categories
Policy

The Word “Mental” in Project 2025. (iii)

Just to formally close out the series on Project 2025 and its intersections with mental health, let me comment on the third instance where “mental” shows up in the document. (The series starts here.) In short, the authors advocate that parents have unconditional and prompt access to all information their children share with schools, including:

surveys, about political affiliations or beliefs; mental or psychological issues (emphasis mine); sexual behaviors or attitudes; critical appraisals of family members; illegal or self-incriminating behavior; religious practices or beliefs; privileged relationships, as with doctors and clergy; and family income, unless for program eligibility.

The section cites two laws, the Family Educational Rights and Privacy Act (FERPA) and Protection of Pupil Rights Amendment (PPRA), both of which reportedly “require[s] schools to obtain parental consent before asking questions”. However, it sounds like some schools do not routinely obtain parental consent to ask questions of students. The authors suggest that concerned parents don’t have many options to enforce these laws.

Here’s the entire (and lengthy) paragraph on page 344:

At the same time, Congress should also consider equipping parents with a private right of action. Two federal laws provide certain privacy protections for students attending educational institutions or programs funded by the department. The Family Educational Rights and Privacy Act (FERPA) protects the privacy of student education records and allows parents and students over the age of 18 to inspect and review the student’s education records maintained by the school and to request corrections to those records. FERPA also authorizes a number of exceptions to this records privacy protection that allow schools to disclose the student’s education records without the consent or knowledge of the parent or student. The Protection of Pupil Rights Amendment (PPRA) requires schools to obtain parental consent before asking questions, including surveys, about political affiliations or beliefs; mental or psychological issues; sexual behaviors or attitudes; critical appraisals of family members; illegal or self-incriminating behavior; religious practices or beliefs; privileged relationships, as with doctors and clergy; and family income, unless for program eligibility. The difficulty for parents is that FERPA and PPRA do not authorize a private right of action. If a school refuses to comply with either statute, the only remedy is for the parent or student (if over the age of 18) to file an administrative complaint with the U.S. Department of Education, which must then work with the school to obtain compliance before taking any action to suspend or terminate federal financial assistance. Investigations can take months if not years. The department has never suspended or terminated the funding for an educational institution or agency for violating FERPA or PPRA. In essence, Congress has granted parents and students important statutory rights without an effective remedy to assert those rights.

In an effort to prevent “perfect” from becoming the enemy of “good enough”, I’ve abandoned trying to learn more about FERPA and PPRA. Rules and regulations related to education are not my expertise. All of us who work in health care, though, can comment on why privacy related to a person’s health is valuable, even if they are not yet 18 years old.

Yes, in an ideal world, all people under the age of 18 have trusting, caring, and safe relationships with their parents or caregivers. Civil conversations about mental health, sexuality, politics, and religion would be norms within households.

However, we don’t live in an ideal world.

There are reasons why young people don’t share their thoughts and feelings with their adults or caregivers. Sometimes the reasons aren’t valid. Young people sometimes underestimate their parents or have unjustified fears about their caregivers’ reactions.

However, there are other instances where a youth’s best option is to withhold information from their parents. Sometimes children feel that they must protect their caregivers. Sometimes kids realize that their parents cannot tolerate another worry. Sometimes children understand that their own health and safety are at risk because of the behavior of their caregivers.

Sometimes kids feel safer and more secure at school.

The authors of Project 2025 start from the assumption that parents know best, that their authority is the ultimate authority. Maybe parents do know best, but they don’t always behave the best. Some adults can and do misuse their authority. (To be clear, this can happen at school, too.)

This push to keep parents as the center of a young person’s life makes me think of Erik Erikson’s stages of psychosocial development. Erikson was a psychologist who came up with a model of psychological developmental milestones. You can review the stages here, which are presented in pairs to highlight the tension of the stage. For young people in school, the relevant stages are:

  • Initiative vs. Guilt
  • Industry vs. Inferiority
  • Identity vs. Identity confusion

Erikson proposed that the stage before “initiative vs. guilt” is “autonomy vs. shame, doubt”. I can’t read the minds of the Project 2025 authors, though in reviewing where the word “mental” shows up in Project 2025, there seems to be an emphasis on limiting the autonomy of multiple groups of people (women, transgender people, youth). External forces can induce feelings of shame and doubt, which people can then internalize. The world gets smaller: You feel constrained in who you can be and what you can do. Shame and doubt are strong inhibitors. Your autonomy disappears.

If we believe that all people have the “unalienable rights of life, liberty and the pursuit of happiness“, that means that we must allow and help people develop their own thoughtful autonomy so they can exercise those rights. Instead of insisting that schools abstain from having conversations about real issues with students, parents and caregivers can help young people develop thoughtful autonomy. Shame and doubt are not inherently bad; these feelings foster social bonds and a cooperative society. We don’t need to fear either autonomy or shame. For our individual and community mental wellness we need both.